Validity and responsiveness of at-home touch-screen assessments in advanced Parkinson's disease

The aim of this study was to investigate if a telemetry test battery can be used to measure effects of Parkinson’s disease (PD) treatment intervention and disease progression in patients with fluctuations. Sixty-five patients diagnosed with advanced PD were recruited in an open longitudinal 36-month study; 35 treated with levodopa-carbidopa intestinal gel (LCIG) and 30 were candidates for switching from oral PD treatment to LCIG. They utilized a test battery, consisting of self-assessments of symptoms and fine motor tests (tapping and spiral drawings), four times per day in their homes during week-long test periods. The repeated measurements were summarized into an overall test score (OTS) to represent the global condition of the patient during a test period. Clinical assessments included ratings on Unified PD Rating Scale (UPDRS) and 39-item PD Questionnaire (PDQ-39) scales. In LCIG-naïve patients, mean OTS compared to baseline was significantly improved from the first test period on LCIG treatment until month 24. In LCIG-non-naïve patients, there were no significant changes in mean OTS until month 36. The OTS correlated adequately with total UPDRS (rho = 0.59) and total PDQ-39 (0.59). Responsiveness measured as effect size was 0.696 and 0.536 for OTS and UPDRS respectively. The trends of the test scores were similar to the trends of clinical rating scores but dropout rate was high. Correlations between OTS and clinical rating scales were adequate indicating that the test battery contains important elements of the information of well-established scales. The responsiveness and reproducibility were better for OTS than for total UPDRS.

Elitidrottsproblem? : En kvalitativ studie om elitidrottares karriäravslutning

This paper used a qualitative technique from a social scientific perspective, a model based on Hewitt and his theory of the self-concept. The purpose of this study was to investigate why some elite athletes experience troublesome periods after their career ending. Interviews were performed with five elite athletes with varying experiences after career ending. The length of the elite athlete careers vary between 7 to 17 years. Two groups were made based upon experiences after career ending. Group 1 had experienced problems, for example suicide tendency, and group 2 had not. The result shows that a troublesome period can come up independently of career ending. The self-concept was investigated during the career and further different kind of variables which could affect the self as training and competition, social relations both before and after termination from sport. Result indicates that an individual in group 2 who has a high complexity in the self-concept based upon significant others outside the elite sport during the career copes with the new situation after career ending much better than group 1 who have not. To build up the self based only upon significant others in the elite sport seems to give expression in a strengthen self. Intensity in training and competition did not have a connection with a troublesome period after retirement from sport but it could prevent establishing contact with others outside the elite sport and reduce a high complexity in the self-concept. The result further shows that elite athletes who practise an individual sport trains in to a greater extent than elite athletes in a seasonal sport. Result also shows that practising a sport with one day off a week, contributes to better opportunities for developing a higher complexity in the self-concept. Suspicions has also rouse that practising an elite sport on the highest level can lead to extensive focusing that further leads to social isolation from individuals outside elite sport. To build up the self upon significant others outside elite sport during the career and keep in touch with significant others from elite sport after the career seems to be the key to avoid problems after the career ending. Suggestions about further investigations are made to see if medial exposure and status can affect the self.

Kreativ förpackningsdesign – förpackningslösningar till chokladpraliner

The Degree Project is about ”creative packaging”, the group has in collaboration with AssiDomän Frövi planned, constructedand designed two packagingsolutions for chocolate creams.The group has worked with the cardboard Frövi Bright produced by the company itself, which together with differentaspects in marketing demands deep knowledge about the chosen material and productgroup.The knowledge wererecieved from education, litterature and personal contacts.The completed packagingsolutions will be exposed in connection with an exhibition this summer.The Degree Project has resulted in two new and completed packagingsolutions for chocolate creams. One is mainlycreative and the other one provides strenghtness with the chosen cardboard.Hopefully the result by the group represents AssiDomän Frövi in a pleasant way and increases the expectations forthe future.

Betydelsen av taktil massage i omvårdnaden av dementa patienter- En systematisk litteraturstudie

Syftet med denna systematiska litteraturstudie var att se vilka effekter taktil massage ger hos personer med demens. Sökning av artiklar har gjorts på databaserna CINAHL, ELIN@Dalarna och PubMed där sökorden dementia, massage, nursing, older people, Therapeutic touch och touch användes i olika kombinationer. Litteraturstudien består av kvantitativa och kvalitativa artiklar. Artiklarna skulle vara vetenskapliga och inte publicerade före 1995, de skulle även svara på syfte och frågeställning. För att säkerställa att kvalitén på artiklarna var hög granskades de med en granskningsmall. Sammanlagt ligger fjorton artiklar till grund för resultatet i denna litteraturstudie. Resultatet visade att taktil massage har goda effekter i omvårdnaden av dementa. Personalen upplevde att de dementa blev hjälpta av taktil massage. De dementa sänkte sina röster och hade inte samma skrikbeteende som innan. Studierna har också visat att tablettanvändning minskade hos patienterna då de regelbundet fick taktil massage. Personalen växte som vårdare då de använde sig av taktil massage. Efter att projektet var avslutat så kände personalen en bättre sammanhållning i gruppen.

Beröring - Ett sätt att få vård. Ett sätt att ge vård. : En systematisk litteraturstudie

Syftet med studien var att belysa faktorer som påverkar äldre, över 65 år, patienters upplevelse av beröring, dess effekter samt belysa sjuksköterskans upplevelse av att ge beröring. Metoden är en systematisk litteraturstudie, baserad på 15 vetenskapliga artiklar sökta via databaserna Cinahl, Cochrane och sökmotorn Elin@dalarna.Resultatet visade att genus, livserfarenhet, yrkeskompetens hos sjuksköterskan, relationer samt vilken del av kroppen som berördes var faktorer som styrde patientens upplevelse av beröring från sjuksköterskan.Sjuksköterskors upplevelse av att ge beröring visades genom en helhetssyn av patienten, ge bekräftelse, vårda med respekt samt kunna beröra på ett naturligt sätt. Beröring visades ha goda effekter både hos den äldre patienten och sjuksköterskan genom att relationsbanden mellan dem styrktes, minskade sömnproblemen samt lindrade smärta, stress och oro hos den äldre patienten.

Lindex - vägen till en tydligare logotyp

Lindex has a strong fashion position and is one of northern Europe's leading fashion retailers. Unfortunately their logotype no longer measures up to the fashion level that is required. Surveys and interviews have been conducted with employees at Lindex, disscusing their logotype. I have come to the conclusion that what is needed from Lindex side is strict guidlines for the employees to follow so that all information from Lindex to their customers is made with a great touch of fashion to it and in a coherent way.

Berörd av beröring : Effekter och användning av beröring på demenssjuka personer- En litteraturstudie

Syftet med denna litteraturstudie var att beskriva olika former av beröring samt dess effekt för personer med sjukdomen demens. Sökningarna har gjorts i databaserna Pubmed, Cinahl och sökmotorn ELIN@du.se med sökorden: massage, dementia, nursing, home, touch, older, patients, therapeutic touch, care och therapy. Artiklarna var utförda mellan år 2000 till 2009 och var kvalitativa och kvantitativa och utgjorde urvalet. För att värdera de utvalda artiklarna användes granskningsmallar. Resultat visade att beröring gav positiva effekter på stress och agiterat beteende såsom skrikbeteende och fysiskt upprört beteende. Beröringen bidrog till att patienterna slappnade av fick lättare att somna. Beröringen minskade oro, depression och nedstämdhet och bidrog till en högre grad av välmående. Beröringen gav däremot ingen effekt på fysiskt aggressivt beteende. Användning av beröring förstärkte relationen mellan vårdare och patient. Beröringen ska ges med full uppmärksamhet till patienten. Patienten ska kunna avbryta beröringen om den upplevs som obehaglig. Slutsatsen som uppsatsförfattarna drog var att beröring gav positiva effekter, oberoende var på kroppen beröringen gavs samt vilken sorts beröring som gavs. Beröringen ska även ske tillsammans med en god kommunikation med den dementa personen för att uppnå bäst resultat.

Personalized Communications : A Cross Media tool for the future

Personalized communication is when the marketing message is adapted to each individual by using information from a databaseand utilizing it in the various, different media channels available today. That gives the marketer the possibility to create a campaign that cuts through today’s clutter of marketing messages and gets the recipients attention. PODi is a non-profit organization that was started with the aim of contributing knowledge in the field of digital printingtechnologies. They have created a database of case studies showing companies that have successfully implemented personalizedcommunication in their marketing campaigns. The purpose of the project was therefore to analyze PODi case studies with the main objective of finding out if/how successfully the PODi-cases have been and what made them so successful. To collect the data found in the PODi cases the authors did a content analysis with a sample size of 140 PODi cases from the year 2008 to 2010. The study was carried out by analyzing the cases' measurable ways of success: response rate, conversion rate, visited PURL (personalized URL:s) and ROI (Return On Investment). In order to find out if there were any relationships to be found between the measurable result and what type of industry, campaign objective and media vehicle that was used in the campaign, the authors put up different research uestions to explore that. After clustering and merging the collected data the results were found to be quite spread but shows that the averages of response rates, visited PURL and conversion rates were consistently very high. In the study the authors also collected and summarized what the companies themselves claim to be the reasons for success with their marketing campaigns. The resultshows that the creation of a personalized campaign is complex and dependent on many different variables. It is for instance ofgreat importance to have a well thought-out plan with the campaign and to have good data and insights about the customer in order to perform creative personalization. It is also important to make it easy for the recipient to reply, to use several media vehicles for multiple touch points and to have an attractive and clever design.

Inkzine : Redesignandet av en tatuerings- och piercingcommunity

Our employer, Gaddad, is a tattoo and piercing community that was created in 2006 with the basic idea to make it easier for people to get in touch with the tattoo artists and piercers from all over Sweden. With the homepage’s popularity at 2009 they decided to expand with the news page Inkzine. 2011 they contacted us with a plan to expand the homepage to Europe and then merge their two sites under the name Inkzine.The goal of this project was to create design suggestions for Gaddad / Inkzine that both the administration and the current users liked and would consider implementing on the website. In order to evaluate the current design and our suggestions we decided to use two questionnaires . The first questionnaire evaluated the currentdesign to provide us with information for the redesign. The second questionnaire evaluated our new suggestions.With these questionnaire we also carried out an analysis to see the differences in opinions among the users and also between the administration and the users.We also investigated other community homepages, company homepages that had been internationalized, and other tattoo homepages. To see what others had done to adapt to the international market and to investigate the design of tattoo homepages.We also did literary studies in redesign and internationalization, in order to obtain a theoretical foundation for our work.The results of the investigation of other homepages showed that in order to perform an internationalization of a web site no major changes to the looks were necessary, only linguistic changes. The results of our questionnairesshowed that users had in most cases put the majority of their votes on

Analysis of tapping test results in a test battery for advanced PD patients

Objective: To compare results from various tapping tests with diary responses in advanced PD. Background: A home environment test battery for assessing patient state in advanced PD, consisting of diary assessments and motor tests was constructed for a hand computer with touch screen and mobile communication. The diary questions: 1. walking, 2. time in off , on and dyskinetic states, 3. off at worst, 4. dyskinetic at worst, 5. cramps, and 6. satisfied with function, relate to the recent past. Question 7, self-assessment, allows seven steps from -3 ( very off ) to +3 ( very dyskinetic ) and relate to right now. Tapping tests outline: 8. Alternately tapping two fields (un-cued) with right hand 9. Same as 8 but using left hand 10. Tapping an active field (out of two) following a system-generated rhythm (increasing speed) with the dominant hand 11. Tapping an active field (out of four) that randomly changes location when tapped using the dominant hand Methods: 65 patients (currently on Duodopa, or candidates for this treatment) entered diary responses and performed tapping tests four times per day during one to six periods of seven days length. In total there were 224 test periods and 6039 test occasions. Speed for tapping test 10 was discardedand tests 8 and 9 were combined by taking means. Descriptive statistics were used to present the variation of the test variables in relation to self assessment (question 7). Pearson correlation coefficients between speed and accuracy (percent correct) in tapping tests and diary responses were calculated. Results: Mean compliance (percentage completed test occasions per test period) was 83% and the median was 93%. There were large differences in both mean tapping speed and accuracy between the different self-assessed states. Correlations between diary responses and tapping results were small (-0.2 to 0.3, negative values for off-time and dyskinetic-time that had opposite scale directions). Correlations between tapping results were all positive (0.1 to 0.6). Conclusions: The diary responses and tapping results provided different information. The low correlations can partly be explained by the fact that questions related to the past and by random variability, which could be reduced by taking means over test periods. Both tapping speed and accuracy reflect the motor function of the patient to a large extent.

A web application for follow-up of results from a mobile device test battery for parkinson’s disease patients

Background: A test battery consisting of self-assessments and motor tests (tapping and spiral drawing) was developed for a hand computer with touch screen in a telemedicine setting. Objectives: To develop and evaluate a web-based system that delivers decision support information to the treating clinical staff for assessing PD symptoms in their patients based on the test battery data. Methods: The test battery is currently being used in a clinical trial (DAPHNE, EudraCT No. 2005-002654-21) by sixty five patients with advanced Parkinson’s disease (PD) on 9991 test occasions (four tests per day during in all 362 week-long test periods) at nine clinics around Sweden. Test results are sent continuously from the hand unit over a mobile net to a central computer and processed with statistical methods. They are summarized into scores for different dimensions of the symptom state and an ‘overall test score’ reflecting the overall condition of the patient during a test period. The information in the web application is organized and presented graphically in a way that the general overview of the patient performance per test period is emphasized. Focus is on the overall test score, symptom dimensions and daily summaries. In a recent preliminary user evaluation, the web application was demonstrated to the fifteen study nurses who had used the test battery in the clinical trial. At least one patient per clinic was shown. Results: In general, the responses from nurses were positive. They claimed that the test results shown in the system were consistent with their own clinical observations. They could follow complications, changes and trends within their patients. Discussion: In conclusion, the system is able to summarise the various time series of motor test results and self-assessments during test periods and present them in a useful manner. Its main contribution is a novel and reliable way to capture and easily access symptom information from patients’ home environment. The convenient access to current symptom profile as well as symptom history provides a basis for individualized evaluation and adjustment of treatments.

12-month results from a novel test battery used in a duodenal levodopa infusion trial

A novel test battery consisting of self-assessments and motor tests (tapping and spiral drawing) for patients with Parkinson’s disease (PD) was developed for a hand computer with touch screen in a telemedicine setting. Tests are performed four times per day in the home environment during weeklong test periods. Results are processed into scores for different dimensions of the symptom state and an ‘overall score’ reflecting the global condition of a patient during a test period. The test battery was validated in a separate study recently submitted to Mov Disord. This test battery is currently being used in an open longitudinal trial (DAPHNE, EudraCT No. 2005- 002654-21) by sixty-five patients with advanced PD at nine clinics around Sweden. On inclusion, the patients were either receiving treatment with duodenal levodopa/carbidopa infusion (Duodopa®) (n=36), or they were candidates for receiving this treatment (n=29). We now present interim results for the first twelve months. Test periods were performed in three-month intervals. During most of the periods, UPDRS ratings were performed in afternoons at the start of the week. In twenty of the patients, scores were available during individually optimized oral polypharamacy, before receiving infusion and at least one test period after having started infusion treatment. Usability and compliance with performing tests, this far are good, both with patients and clinical staff. Correlations between test periods 2 and 3 during infusion treatment (three months apart) are stronger for overall test score than for total UPDRS, indicating good reliability. The correlation between overall test score and UPDRS for all test periods is adequate (r=-0.6). In an exact Wilcoxon signed rank test, where the endpoint is the change from the first to the twelve month test period (n=25), there was no change in test results in any of the test battery dimensions for the patients already receiving infusion when included. However, in the patients entering the study before receiving infusion, there was a significant change (improvement) from the baseline to the twelve month test period in dimensions; ‘off’, ‘dyskinesia’ and ‘satisfied’ and in the ‘overall score’ (n=15). The mean improvement in overall score after infusion was 29% (p=0.015). We conclude that the test battery is able to measure a functional improvement with infusion that is sustained over at least twelve months.

Computerized identification of motor complications in Parkinson's disease

Objective: To investigate whether spirography-based objective measures are able to effectively characterize the severity of unwanted symptom states (Off and dyskinesia) and discriminate them from motor state of healthy elderly subjects. Background: Sixty-five patients with advanced Parkinson’s disease (PD) and 10 healthy elderly (HE) subjects performed repeated assessments of spirography, using a touch screen telemetry device in their home environments. On inclusion, the patients were either treated with levodopa-carbidopa intestinal gel or were candidates for switching to this treatment. On each test occasion, the subjects were asked trace a pre-drawn Archimedes spiral shown on the screen, using an ergonomic pen stylus. The test was repeated three times and was performed using dominant hand. A clinician used a web interface which animated the spiral drawings, allowing him to observe different kinematic features, like accelerations and spatial changes, during the drawing process and to rate different motor impairments. Initially, the motor impairments of drawing speed, irregularity and hesitation were rated on a 0 (normal) to 4 (extremely severe) scales followed by marking the momentary motor state of the patient into 2 categories that is Off and Dyskinesia. A sample of spirals drawn by HE subjects was randomly selected and used in subsequent analysis. Methods: The raw spiral data, consisting of stylus position and timestamp, were processed using time series analysis techniques like discrete wavelet transform, approximate entropy and dynamic time warping in order to extract 13 quantitative measures for representing meaningful motor impairment information. A principal component analysis (PCA) was used to reduce the dimensions of the quantitative measures into 4 principal components (PC). In order to classify the motor states into 3 categories that is Off, HE and dyskinesia, a logistic regression model was used as a classifier to map the 4 PCs to the corresponding clinically assigned motor state categories. A stratified 10-fold cross-validation (also known as rotation estimation) was applied to assess the generalization ability of the logistic regression classifier to future independent data sets. To investigate mean differences of the 4 PCs across the three categories, a one-way ANOVA test followed by Tukey multiple comparisons was used. Results: The agreements between computed and clinician ratings were very good with a weighted area under the receiver operating characteristic curve (AUC) coefficient of 0.91. The mean PC scores were different across the three motor state categories, only at different levels. The first 2 PCs were good at discriminating between the motor states whereas the PC3 was good at discriminating between HE subjects and PD patients. The mean scores of PC4 showed a trend across the three states but without significant differences. The Spearman’s rank correlations between the first 2 PCs and clinically assessed motor impairments were as follows: drawing speed (PC1, 0.34; PC2, 0.83), irregularity (PC1, 0.17; PC2, 0.17), and hesitation (PC1, 0.27; PC2, 0.77). Conclusions: These findings suggest that spirography-based objective measures are valid measures of spatial- and time-dependent deficits and can be used to distinguish drug-related motor dysfunctions between Off and dyskinesia in PD. These measures can be potentially useful during clinical evaluation of individualized drug-related complications such as over- and under-medications thus maximizing the amount of time the patients spend in the On state.

Visualization of spirography-based objective measures in Parkinson's disease

Objective: To investigate whether advanced visualizations of spirography-based objective measures are useful in differentiating drug-related motor dysfunctions between Off and dyskinesia in Parkinson’s disease (PD). Background: During the course of a 3 year longitudinal clinical study, in total 65 patients (43 males and 22 females with mean age of 65) with advanced PD and 10 healthy elderly (HE) subjects (5 males and 5 females with mean age of 61) were assessed. Both patients and HE subjects performed repeated and time-stamped assessments of their objective health indicators using a test battery implemented on a telemetry touch screen handheld computer, in their home environment settings. Among other tasks, the subjects were asked to trace a pre-drawn Archimedes spiral using the dominant hand and repeat the test three times per test occasion. Methods: A web-based framework was developed to enable a visual exploration of relevant spirography-based kinematic features by clinicians so they can in turn evaluate the motor states of the patients i.e. Off and dyskinesia. The system uses different visualization techniques such as time series plots, animation, and interaction and organizes them into different views to aid clinicians in measuring spatial and time-dependent irregularities that could be associated with the motor states. Along with the animation view, the system displays two time series plots for representing drawing speed (blue line) and displacement from ideal trajectory (orange line). The views are coordinated and linked i.e. user interactions in one of the views will be reflected in other views. For instance, when the user points in one of the pixels in the spiral view, the circle size of the underlying pixel increases and a vertical line appears in the time series views to depict the corresponding position. In addition, in order to enable clinicians to observe erratic movements more clearly and thus improve the detection of irregularities, the system displays a color-map which gives an idea of the longevity of the spirography task. Figure 2 shows single randomly selected spirals drawn by a: A) patient who experienced dyskinesias, B) HE subject, and C) patient in Off state. Results: According to a domain expert (DN), the spirals drawn in the Off and dyskinesia motor states are characterized by different spatial and time features. For instance, the spiral shown in Fig. 2A was drawn by a patient who showed symptoms of dyskinesia; the drawing speed was relatively high (cf. blue-colored time series plot and the short timestamp scale in the x axis) and the spatial displacement was high (cf. orange-colored time series plot) associated with smooth deviations as a result of uncontrollable movements. The patient also exhibited low amount of hesitation which could be reflected both in the animation of the spiral as well as time series plots. In contrast, the patient who was in the Off state exhibited different kinematic features, as shown in Fig. 2C. In the case of spirals drawn by a HE subject, there was a great precision during the drawing process as well as unchanging levels of time-dependent features over the test trial, as seen in Fig. 2B. Conclusions: Visualizing spirography-based objective measures enables identification of trends and patterns of drug-related motor dysfunctions at the patient’s individual level. Dynamic access of visualized motor tests may be useful during the evaluation of drug-related complications such as under- and over-medications, providing decision support to clinicians during evaluation of treatment effects as well as improve the quality of life of patients and their caregivers. In future, we plan to evaluate the proposed approach by assessing within- and between-clinician variability in ratings in order to determine its actual usefulness and then use these ratings as target outcomes in supervised machine learning, similarly as it was previously done in the study performed by Memedi et al. (2013).

Mobile systems for monitoring Parkinson's disease

A challenge for the clinical management of Parkinson's disease (PD) is the large within- and between-patient variability in symptom profiles as well as the emergence of motor complications which represent a significant source of disability in patients. This thesis deals with the development and evaluation of methods and systems for supporting the management of PD by using repeated measures, consisting of subjective assessments of symptoms and objective assessments of motor function through fine motor tests (spirography and tapping), collected by means of a telemetry touch screen device. One aim of the thesis was to develop methods for objective quantification and analysis of the severity of motor impairments being represented in spiral drawings and tapping results. This was accomplished by first quantifying the digitized movement data with time series analysis and then using them in data-driven modelling for automating the process of assessment of symptom severity. The objective measures were then analysed with respect to subjective assessments of motor conditions. Another aim was to develop a method for providing comparable information content as clinical rating scales by combining subjective and objective measures into composite scores, using time series analysis and data-driven methods. The scores represent six symptom dimensions and an overall test score for reflecting the global health condition of the patient. In addition, the thesis presents the development of a web-based system for providing a visual representation of symptoms over time allowing clinicians to remotely monitor the symptom profiles of their patients. The quality of the methods was assessed by reporting different metrics of validity, reliability and sensitivity to treatment interventions and natural PD progression over time. Results from two studies demonstrated that the methods developed for the fine motor tests had good metrics indicating that they are appropriate to quantitatively and objectively assess the severity of motor impairments of PD patients. The fine motor tests captured different symptoms; spiral drawing impairment and tapping accuracy related to dyskinesias (involuntary movements) whereas tapping speed related to bradykinesia (slowness of movements). A longitudinal data analysis indicated that the six symptom dimensions and the overall test score contained important elements of information of the clinical scales and can be used to measure effects of PD treatment interventions and disease progression. A usability evaluation of the web-based system showed that the information presented in the system was comparable to qualitative clinical observations and the system was recognized as a tool that will assist in the management of patients.